Tenn. Comp. R. & Regs. 0780-01-71-.11
(1) Life insurance companies authorized to do business in this state shall respond to a request for verification of coverage from a life settlement provider or a life settlement broker within thirty (30) calendar days of the date a request is received, subject to the following conditions:
(c) In the case of group insurance coverage:
Authority: T.C.A. §56-50-110. Administrative History: Original rule filed February 7, 2003; effective April 23, 2003. APPENDIX A VERIFICATION OF COVERAGE FOR INDIVIDUAL POLICIES Section One: (To be completed by the Life Settlement Provider or Life Settlement Broker) Insurance Company: Name of Policy Owner: Policy Number: Policy Owner’s Social Security Number: Name of Insured: Policy Owner’s Address: (Street) Insured’s date of birth: (City/State) Please provide the information requested in Section Two (below) with regard to the policy identified above and in accordance with the attached authorization. In addition, please provide the forms checked below which are available from your company to complete a life settlement transaction: Absolute Assignment/Change of Ownership/Life Assignment Form Change of Beneficiary Release of Irrevocable Beneficiary (if applicable) Waiver of Premium Claim Form Disability Waiver of Premium Approval Letter Date Signature of a representative of Life Settlement Broker or Life Settlement Provider Full name and address of Life Settlement Broker or Life Settlement Provider Section Two: (To be completed by the life insurance company) 1) Face amount of policy: $ 2) Original date of issue: / / Month/Date/Year) 3) Was face amount increased after original issue date? no yes a) If yes, when: / / b) Amount of increase $__________ 4) Type of policy: (Term/Whole Life/Universal Life/Variable Life) 5) Is policy participating? no yes a) If yes, what is current dividend election? 6) Current net death benefit: (Enter full amount payable, including any additional insurance, and/or dividends accumulated at interest, minus policy loans, outstanding interest on policy loans and/or accelerated death benefits paid) 7) a) Current cash value: $ (Enter full amount, including cash value of any additional insurance and/or dividends accumulated at interest, minus policy loans and outstanding interest on policy loans b) Current surrender value: $ c) Is the Cash Value paid to the Beneficiary in addition to the Face Amount? no yes d) Is there collateral assignment against this policy now? no yes If yes, Assignee of record: __________________________ e) What is the length of the contestability period? Current beyond contestability? no yes f) Is this a Group Conversion? no yes If yes, is the contestability period waived? no yes 8) Terms of policy loans: a) Amount of policy loans taken: $ b) Amount of outstanding interest on policy loan: $ c) Current interest rate: 9) Has policy lapsed? no yes a) If yes, when did policy lapse? / / If policy has lapsed, is coverage continued under non-forfeiture option? no yes If yes, indicate which option, amount of coverage, duration, etc.: 10) Is policy in force? no yes a) If yes, has the policy been reinstated within the last two years? no yes If yes, date of reinstatement: / / 11) Amount of contract/scheduled premiums: $ 12) Current premium mode: (Monthly, semi-annually, etc.) a) When is next premium due? / / (Month/Day/Year) 13) Does the policy include a disability premium waiver provision/rider? no yes a) If yes, are premiums currently being waived? no yes b) If yes, since when? / / c) How often is continued eligibility reviewed? d) When is next review? / / 14) Can payment of all or part of the death benefit be accelerated under this policy? no yes a) If yes, by what method is the benefit calculated, the lien method or the discount method? b) If lien method, what is the interest rate? c) Can any remaining death benefit be assigned? no yes 15) Has a claim for accelerated death benefit been submitted? no yes a) If yes, was payment made under this provision? no yes Amount paid: Date paid: 16) Do current records show any assignments of record? no yes 17) Do current records show any outstanding liens or encumbrances or collateral assignments of record? no yes If yes, please give name: ___________________________ 18) Please identify current primary beneficiaries: a) Are they named irrevocably, or is owner otherwise limited in designation of new beneficiaries? no yes 19) Have any riders been added to this policy after issue? no yes If yes, please identify: 20) If an ownership or beneficiary change or assignment were to be made on this policy, to whom would the completed forms be sent for recording? Name: Title: Company Name: Department: Address (No P.O. Box, please) City: State: ZIP: Telephone No: Fax: The answers provided reflect information contained in the company’s records as of: (date) Signature: Name: (Printed) Title: Company: Direct Telephone No: Direct Fax No: APPENDIX B VERIFICATION OF GROUP LIFE INSURANCE BENEFITS Section One: (To be completed by the Life Settlement Provider or Life Settlement Broker Insurance Company Name of Employee/Member Employer/Policyholder Name Insured’s Date of Birth Policy Number Insured’s Social Security Number Certificate Number Employee/Membership Number Please provide the information requested in Section Two or Section Three, as appropriate, with regard to the individual and coverage described, in accordance with the attached authorization. In addition, please provide the forms checked below which are available from your company to complete a life settlement transaction: Absolute Assignment Change of Beneficiary (irrevocable if applicable) Disability Waiver of premium claim or Disability Waiver of premium award letter __ Date Signature of a representative of Life Settlement Broker or Life Settlement Provider Full name and address of Life Settlement Broker or Life Settlement Provider Section Two: (To be completed by the employer/group policyholder and the insurer. Both should indicate the parts they completed.) 1) BASIC COVERAGE: a) Is the plan self-insured or is coverage provided under a group policy issued by a life insurance company? b) Name of plan administrator: ___________________________________________ If by a group policy, please provide the name of the insurance company for BASIC life insurance coverage: c) Effective date of BASIC life insurance coverage: d) Face amount of BASIC life insurance: e) Does the amount of coverage decrease for any reason? no yes If yes, please explain: _______________________________________________ f) Does BASIC coverage plan have contestable provisions? no yes If yes, what is the length of the provision and when does it end: _____________________________________________________________ g) Is BASIC coverage subject to a suicide provision? no yes If yes, what is the length of the provision and when does it end: _____________________________________________________________ h) Monthly premium paid by employer/group policyholder for BASIC life insurance: $ i) Certificate Number: _____________________________________________ j) Monthly premium paid by employee/insured for BASIC life insurance: $ k) Is BASIC life insurance coverage Term Universal Life? i) If Universal Life, please indicate cash value, if any: Is this amount payable in addition to the face amount? no yes l) Is coverage in force? no yes m) Has the policy ever lapsed? no yes If yes, date of lapse _____/_____/____ n) At the time of the original application, was the insured required to have a medical or non-medical examination, including blood work? no yes o) When is next premium due? p) Has employee’s coverage under this plan ever been reinstated? no yes i) If yes, date of reinstatement: q) Is the employee presently working? no yes If no, is the employee on approved waiver of premium? no yes If no, is the waiver of premium pending? no yes How long will the waiver of premium continue? _______________________ What is the date of the last day worked by the employee? ______/______/______ r) If the employee terminates before a period of 3 to 5 years, can the policy be converted to an individual policy? no yes If yes, how much of the total face amount can be converted? $________________ Is the conversion to an individual policy guaranteed without a medical examination or medical questions? no yes 2) SUPPLEMENTAL (OPTIONAL) COVERAGE a) Insurance Company for SUPPLEMENTAL life insurance coverage: b) Effective date of SUPPLEMENTAL life insurance coverage: c) Face amount of SUPPLEMENTAL life insurance: d) Does SUPPLEMENTAL coverage plan have contestable provisions? no yes e) Is SUPPLEMENTAL coverage subject to a suicide provision? no yes f) Monthly premium paid by employer/group policyholder for SUPPLEMENTAL life insurance: $ g) Monthly premium paid by employee/insured for SUPPLEMENTAL life insurance: $ h) Is SUPPLEMENTAL life insurance coverage Term Universal Life? i) If Universal Life, please indicate cash value, if any: Is this amount payable in addition to the face amount? no yes i) Is coverage in force? no yes j) When is next premium due? k) Has employee’s coverage under this policy been reinstated within the last two years? no yes i) If yes, date of reinstatement: 3) DISABILITY WAIVER OF PREMIUM a) Does plan provide for waiver of premium in the event of employee/insured’s disability? BASIC no yes What is the waiting period? ___________ SUPPLEMENTAL no yes What is the waiting period? _____________ b) Are premiums currently being waived under disability premium waiver? BASIC? no yes SUPPLEMENTAL? no yes c) Who pays premiums under disability premium waiver? BASIC Insurance carrier Employer SUPPLEMENTAL Insurance carrier Employer d) What was the date of approval? e) Next review date? f) Does the employer continue to pay the premium while the insured is on the “elimination period”? g) Does the insured have to pay to keep the coverage in force? h) If the insured is no longer eligible for waiver, what amount of coverage can be converted to an individual policy? $ i) Will a new suicide/contestability clause be in effect for the converted policy? no yes ii) Will assignee be notified if insured is no longer eligible for waiver? no yes Does the assignee have the right without the insured’s participation to convert the policy? no yes i) Does the employer continue to pay the premium while the insured is on the “elimination period”? no yes j) Does the insured have to pay to keep the coverage in force? no yes 4) BENEFICIARIES, ASSIGNMENTS AND LIMITATIONS a) Who are the primary beneficiaries of the coverage(s)? BASIC SUPPLEMENTAL: b) Is any beneficiary under this policy designated irrevocably, or is insured otherwise limited in designation of new beneficiaries? no yes c) Can this coverage be assigned? BASIC no yes If yes, to a corporation? no yes To someone not related to insured? no yes SUPPLEMENTAL no yes If yes, to a corporation? no yes To someone not related to insured? no yes d) Can the BASIC and SUPPLEMENTAL policy be assigned for value? no yes e) Do records show any assignments of record? no yes f) Do records show any outstanding liens or encumbrances of record? no yes g) Are there any collateral assignments on the policy? no yes If yes, please provide the name of the assignee: _________________________ h) The following parties (as applicable) should indicate whether they will provide notice to the assignee if the master policy is terminated. Group policyholder no yes Third party administrator (if any) no yes Insurance company no yes i) Can Assignee convert the coverage without the permission of insured? no yes 6) ACCELERATED DEATH BENEFITS a) Is there an Accelerated Death Benefit available under the coverage? BASIC no yes SUPPLEMENTAL no yes b) Has request for Accelerated Death Benefit been made? no yes c) Has payment been made to insured under this provision? no yes i) Amount paid: Date paid: ii) Is this amount a lien against death proceeds? no yes Interest rate iii) Can the remaining death benefit be assigned? no yes 7) MISCELLANEOUS a) Is coverage portable? BASIC no yes SUPPLEMENTAL no yes b) If insured is no longer eligible for coverage under the group, will Assignee be notified? no yes c) If master policy discontinues, what amount can be converted to an individual policy? $________ d) Is this plan administered by a third party? no yes If yes, please provide the name, address and telephone number of administrator: Name: Title Company name: Department: Street Address: (No P.O. Box please) City: State: Zip: Telephone number: ( ) Fax: ( ) If a change of beneficiary form or assignment were to be made for this coverage, to whom should the completed forms be sent? Name: Title Company name: Department: Street Address: (No P.O. Box please) City: State: Zip: Telephone number: ( ) Fax: ( ) 1) How much insurance can be converted if the master contract terminates? $______________ 2) How much insurance can be converted is the insured terminates employment before five years? $_________________ 3) Can the assignee convert the entire settled/ viaticated death benefit if the insured is on DPW and the master contract terminates? no yes 4) Is the insured on short term disability? no yes If yes, when does the insured become eligible for long term disability? 5) Is the insured on long term disability? no yes If yes, can the assignee convert the entire settled/ viaticated death benefit should the insured’s disability cease? 6) What is the insured’s current employment status? _______________ The answers provided reflect information in our files as of (date) Signature: Name: Date: Title: Company: Direct telephone number: ( ) Direct fax number: ( ) Information not provided by the employer may be obtained from the insurance company if different from administrator identified above: Name: Title Company name: Department: Address: City: State: Zip: Telephone number: ( ) Fax: ( ) Section Three: The insurance company or the third party administrator named above is requested to complete the information not provided by the employer in Section Two, above, Items number: The answers provided to the identified questions reflect information in the files of the insurance company as of (date) Signature: Name: Date: Title: Company: Direct telephone number: ( ) Direct fax number: ( )